General Practice Guide to Rheumatology - PowerPoint PPT Presentation

General Practice Guide to Rheumatology. Dr Helen Gabathuler MRCP, MRCGP General practitioner and clinical assistant in rheumatology . Aims. History and Examination Appropriate Investigations Management Common conditions in general practice Must Not Miss Diagnoses.

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Abnormalities are commonly found on magnetic resonance imaging scans. A review of eight studies of magnetic resonance imaging in asymptomatic adults found

Bulging discs in 20% to 79%

Herniated discs in 9% to 76%

Degenerative discs in 46% to 91%.

A randomised controlled trial found no difference in clinical outcome between patients who had a rapid magnetic resonance imaging scan and patients who had an x ray of the lumbar spine.

Radiographic imaging for chronic non-specific low back pain is not recommended. However, MRI scans are recommended for the investigation of patients who may have malignancy or sepsis as a cause of their pain and for the investigation of radicular symptoms.

A chronic disorder characterized by softening and disintegration of articular cartilage, with reactive phenomena such as vascular congestion and osteoblastic activity in the subarticular bone, new growth of cartilage and bone (osteophytes) at the joint margins, and capsular fibrosis.

Osteoarthritis is not accompanied by any systemic illness, and although there are sometimes signs of inflammation, it is not primarily an inflammatory disorder.

24 year old male plumber presented with 6 month history of low back pain. No radiation. No neurological, urinary or bowel symptoms. Described stiffness after rest, and when awakens in morning. Takes time to ‘get going ‘in morning after getting out of bed.

What is your provisional diagnosis?

What else would you like to find out?

On further questioning you find out that this has been a recurrent problem for a few years. He has a father with a very bad back, and a cousin. His morning stiffness is lasting up to 2 hours. He has had an episode of uveitis in past when needed to attend eye casualty.

24 year old male plumber presented with 6 month history of low back pain. No radiation. No neurological, urinary or bowel symptoms. Described stiffness after rest, and when awakens in morning. Takes time to ‘get going ‘in morning after getting out of bed.

A 55 year old lady presents with a 3 month history of painful hands. She appears very anxious. She describes difficulty using her hands and stiffness, as well as some swelling.

What are your provisional thoughts on diagnoses?

What else would you like to know?

On further questioning she describes stiffness after rest, and in morning of up to 45 minutes. She is struggling to do up buttons and play the piano. She is very anxious as her job is a piano teacher. She has noticed her finger joints swelling and cannot get her ring off. She has also had knee pain bilaterally for 6 months with use. Her mother had ‘arthritis’ but she doesn’t know which type.

What other symptoms should you ask about? And what other systems should you enquire into?

She has no dry eyes, or dry mouth, nor symptoms of Raynaud’s; she has developed a dry cough last 6 weeks, but no pain nor shortness of breath. Weight stable. Non-smoker.

On further questioning she describes stiffness after rest, and in morning of up to 45 minutes. She is struggling to do up buttons and play the piano. She is very anxious as her job is a piano teacher. She has noticed her finger joints swelling and cannot get her ring off. She has also had knee pain bilaterally for 6 months with use. Her mother had ‘arthritis’ but she doesn’t know which type.

What other symptoms should you ask about? And what other systems should you enquire into?

A 71 year old lady presents with a 2/12 history of a painful right shoulder. She has also noticed some discomfort in her left shoulder. She is unable to get her sweater over her head in the morning.

What are your provisional thoughts on diagnosis?

What else would you like to know?

Other symptoms include flu-like illness 2-3/12 ago from which she never quite recovered, and aching developing in her buttocks. She is extremely stiff in her shoulders in the morning. No other symptoms of note.

What other specific symptoms MUST you ask about in this case?

What other questions are warranted?

She has no scalp tenderness, jaw claudication, visual disturbances or headache.

A 74 year old man presents with a painful swollen knee. It has developed over the past few days. He has an extensive past medical history and is on multiple medication including furosemide and warfarin.

What are your preliminary thoughts on possible diagnoses?

What other questions would you ask?

He has no history trauma to knee, no previous episodes like this. No systemic symptoms. Knee is stiff and painful constantly. Prior to this had noticed occasional aching in hips with exercise. No other joints affected. Is due an INR check.

What are your preliminary differential diagnoses?

What would you like to examine?

Right knee hot, tender and swollen with an effusion, left knee mild crepitus, both hips slight discomfort with rotation and abduction. No skin bruising generally, apyrexial and well, no evidence gouty tophi.

Does this help your differential diagnosis?

What investigations and further management would you undertake? What complicating factors will affect this patient’s management?

A 74 year old man presents with a painful swollen knee. It has developed over the past few days. He has an extensive past medical history and is on multiple medication including furosemide and warfarin.

Birefringence, or double refraction, is the splitting of a ray of light into two rays when it passes through certain types of material, such as calcitecrystals. The two rays, called the ordinary ray and the extraordinary ray, travel at different speeds. Thus the material has two distinct indices of refraction, as measured from different directions.

If split ray of light is rotated clockwise is classified as positive birefringent.